title: Systematic review and meta-analysis of intrauterine adhesions after miscarriage: prevalence, risk factors and long-term reproductive outcome.
abstract: BACKGROUND
  Approximately 15-20% of all clinically confirmed pregnancies end in a miscarriage. Intrauterine adhesions (IUAs) are a possible complication after miscarriage, but their prevalence and the contribution of possible risk factors have not been elucidated yet. In addition, the long-term reproductive outcome in relation to IUAs has to be elucidated.
  
  
  METHODS
  We systematically searched the literature for studies that prospectively assessed the prevalence and extent of IUAs in women who suffered a miscarriage. To be included, women diagnosed with a current miscarriage had to be systematically evaluated within 12 months by hysteroscopy after either spontaneous expulsion or medical or surgical treatment. Studies that included women with a history of recurrent miscarriage only or that evaluated the IUAs after elective abortion or beyond 12 months after the last miscarriage were not included. Subsequently, long-term reproductive outcomes after expectant (conservative), medical or surgical management were assessed in women with and without post-miscarriage IUAs.
  
  
  RESULTS
  We included 10 prospective studies reporting on 912 women with hysteroscopic evaluation within 12 months of miscarriage and 8 prospective studies, including 1770 women, reporting long-term reproductive outcome. IUAs were detected in 183 women, resulting in a pooled prevalence of 19.1% [95% confidence interval (CI): 12.8-27.5%]. The extent of IUAs was reported in 124 women (67.8%) and was mild, moderate and severe respectively in 58.1, 28.2 and 13.7% of cases. Relative to women with one miscarriage, women with two or three or more miscarriages showed an increased risk of IUAs by a pooled OR of 1.41 and 2.1, respectively. The number of dilatation and curettage (D&C) procedures seemed to be the main driver behind these associations. A total of 150 congenital and acquired intrauterine abnormalities were encountered in 675 women, resulting in a pooled prevalence of 22.4% (95% CI: 16.3-29.9%). Similar reproductive outcomes were reported subsequent to conservative, medical or surgical management for miscarriage, although the numbers of studies and of included women were limited. No studies reported long-term reproductive outcomes following post-miscarriage IUAs.
  
  
  CONCLUSIONS
  IUAs are frequently encountered, in one in five women after miscarriage. In more than half of these, the severity and extent of the adhesions was mild, with unknown clinical relevance. Recurrent miscarriages and D&C procedures were identified as risk factors for adhesion formation. Congenital and acquired intrauterine abnormalities such as polyps or fibroids were frequently identified. There were no studies reporting on the link between IUAs and long-term reproductive outcome after miscarriage, while similar pregnancy outcomes were reported subsequent to conservative, medical or surgical management. Although this review does not allow strong clinical conclusions on treatment management, it signals an important clinical problem. Treatment strategies are proposed to minimize the number of D&C in an attempt to reduce IUAs.
authors.affiliation: Department of Obstetrics and Gynaecology, Zaans Medical Center, Zaandam, The Netherlands.
authors.forename: Angelo B
authors.initials: AB
authors.lastname: Hooker
authors.forename: Marike
authors.initials: M
authors.lastname: Lemmers
authors.forename: Andreas L
authors.initials: AL
authors.lastname: Thurkow
authors.forename: Martijn W
authors.initials: MW
authors.lastname: Heymans
authors.forename: Brent C
authors.initials: BC
authors.lastname: Opmeer
authors.forename: Hans A M
authors.initials: HA
authors.lastname: Brölmann
authors.forename: Ben W
authors.initials: BW
authors.lastname: Mol
authors.forename: Judith A F
authors.initials: JA
authors.lastname: Huirne
mesh_terms: D000022:Abortion, Spontaneous / Q000209:etiology*; D005260:Female; D006801:Humans; D007247:Infertility, Female / Q000209:etiology / Q000473:pathology; D011247:Pregnancy; D011256:Pregnancy Outcome; D015995:Prevalence; D012307:Risk Factors; D000267:Tissue Adhesions / Q000453:epidemiology / Q000209:etiology / Q000473:pathology; D014591:Uterine Diseases / Q000453:epidemiology / Q000209:etiology / Q000473:pathology / Q000601:surgery
keywords: adhesions; infertility; miscarriage; reproductive outcome; systematic review